Alternate Submission Form

Please submit the following information
Your First and Last Name*
Your Company*
Your Email Address*
Full Name of Claimant*
Claim File Number*
Claimant Address - Please include City/State/Zip
Claimant Phone (if known)
Date of Incident*
Date Format: MM slash DD slash YYYY
Claimant DOB
Date Format: MM slash DD slash YYYY
Last 4 digits of SSN
Claimant Occupation
Description of Incident*
I have a photo or doc with additional file information
Select Services - Choose any combination
Social Media Searches
- Social Media with Scan Now Technology
Medical Canvass
- 50 location sweep $450
Criminal Records search
- National Records - $50
Physical Surveillance
- 1 Day
- 2 Days
- 3 Days
- 4 Days
- 5 Days
- Custom (indicate in notes field)
Anything Else?
Notes to the Investigator
Email
This field is for validation purposes and should be left unchanged.